Ethics in Modern Practice of Traditional Chinese Medicine (TCM). Scope of Responsible Practice
Part II. Scope of Responsible Practice
Principle: It is essential that practitioners maintain and actively promote the integrity of Chinese medicine and be scrupulous in evaluating any diagnostic or therapeutic approach which is not an authentic part of TCM that might be incorporated into a TCM practice.
Problem: Many practitioners in the West have quickly added to their TCM practice both diagnostic and therapeutic methods that have these characteristics: they have no basis in TCM; they have no support in modern medicine (the accepted medical system in the Western culture); and they can taint the field of TCM for all practitioners.
a) One of the primary attractions of TCM is that it has a long history of use, that it has been and continues to be extensively used in its country of origin, and that its component parts are unified by a relatively consistent dogma. Patients going to practitioners of Chinese medicine have a reasonable expectation of being provided authentic TCM services, reflecting the best and safest practices from China (or, under the heading Oriental medicine, from Japan, Korea, and other countries that adopted Chinese medical concepts and practices). Chinese medicine is recognized as being a system that, like other health care systems, is liable to be adversely affected by deception, quackery, practice by untrained people, and similar problems whereby patients might be exploited by practitioners either wilfully or without realizing it (even with best of intentions). Traditional Chinese medicine literature refers to many instances where these problems arose in China. Patients going to practitioners who are licensed by their respective State governments have a reasonable expectation that such fraudulent and non-authentic or amateur practices have been weeded out via the required educational process, the testing and licensing processes, and monitoring of practitioners in practice. However, there are defects in the current system that allow practitioners to ignore their scope of practice and incorporate techniques not consistent with authentic TCM and not consistent with the high standards of education and monitoring that are expected.
b) Patients can reasonably expect that practitioners of TCM have undergone rigorous, prolonged training and appropriate internship in order to understand their field of expertise and carry out its techniques with adequate knowledge and skill. Practitioners usually graduate from accredited schools, work (as students) in professionally supervised clinics, and meet requirements for competence and understanding that are to be maintained and expanded through approved continuing education, as established by state and national organizations. Unfortunately, when adding other techniques to the practice of TCM, a practitioner might receive little training and the training might be provided by a person who would not meet qualifications consistent with accreditation of schools; the techniques may be ones that are not acceptable within the approved programs or in accordance with their standards, or the board responsible for monitoring and approving such courses may fail to do its important duty of careful oversight. Practitioners and their patients will not have a means for evaluating the training that is received nor the level of competence gained in use of these methods.
c) TCM is regarded, by most practitioners and educators in the field, as a system of great depth, one which requires years of effort to master, far beyond the basics learned in a college program. Most of those who are highly accomplished in TCM will acknowledge that even they still have much more to learn. By adopting non-TCM approaches into the clinical work, the practitioner may be diverted from further investigation of his/her field of expertise and licensing, particularly if the adopted methods are proclaimed (usually without proof) to resolve difficulties of practice that would otherwise require much study and effort. The problem is compounded when practitioners adopt non-TCM methods soon after completing their basic training, before getting a depth of knowledge and experience from working with TCM; because of limited experience, they may not be able to distinguish between authentic TCM and other methods that are popular fads.
That these basic issues are not new and not unique to the Western situation can be illustrated by quoting from Qing Dynasty authors. Huai Yuan wrote a warning to physicians of his day, in a book dating from 1808 (Unschuld 1979):
“In medical practice one cannot act at one’s own discretion. Patients entrust physicians with the decision over their life and their death….[the physician] searches for the causes and considers the consequences. He knows the normal and understands the changes….A physician plans in detail and thinks comprehensively. He observes a disease and takes precautions against it to avoid a second. He is glad over a success and yet he is aware that one cannot repose on this… Those, however, who surrender to fashionable trends do not carry out their practice conscientiously. They place themselves in the greatest light and make use of the need of others in order to appropriate their material goods to themselves…. A physician has to love and respect himself; only then will he, when he faces a grave disease, possess enough trust in himself. I have studied at great length and in any diagnosis of a disease, I proceed with exactitude and conscientiousness; how could I carelessly acquit myself of that which others have entrusted to me and which I have promised to them? Every patient has to consider the practicing physician a trustworthy person. A physician may examine the respectable [methods] without any further consideration. Yet, if he meets with the disreputable, he is first to assure himself of all the details related to it before making a decision.”
Xu Dachun, (writing 50 years earlier, in 1757), also warned physicians about the ease of deceiving patients with wrong ideas (Unschuld 1990):
“The fact is that patients are people who do not know anything about medicine…. When the patients meet someone who knows a little about medical principles, and [who] offers clear-cut discourse and discussion, they will believe what they hear, especially if he displays extraordinary concern and if emotions and face are involved. Who knows that this talk is based on superficial reading and stands for nothing but gossip? Before the people offering [these things] have considered what will happen to the patients following their advice, the patients will have already followed them….. As a result, they recklessly treat people’s illnesses and if these illnesses heal, they consider this their own achievement. If the patient dies, they have done no wrong. They cling only more strongly to their one-sided views….they go on and write books and establish doctrines of their own, and thusly bequeath harm even to later generations. There are so many such people—one cannot count them.”
Although Xu mentions the extreme case of a person dying, which is usually not the situation in modern times, he gives a good analysis; it is easy for a person to claim credit for any improvements that a patient has, and to disregard failures: in the modern situation, a patient doesn’t die but simply decides not to come back for another treatment, and the practitioner doesn’t see a failure, only keeping awareness of those who come back again and again.
Huai, Xu, and other Chinese commentators were aware that many practitioners of TCM could easily be distracted from their medicine by promulgators of disreputable techniques and from hearing presentations by charismatic speakers. They worried about people doing superficial investigations and introducing methods that were based on gossip and emotion-based claims. The same can and does happen in the modern world. Practitioners of TCM in the West are particularly susceptible because they are working within a culture that is not inherently supportive of their efforts, where the medicine they are licensed to practice is already considered an alternative to what is widely accepted. As a result, the ethical barrier to invasive, superficial, and distracting ideas, a valuable barrier that should exist, is sometimes left too porous or removed altogether. The requirement for an ethical barrier is not a matter of having a closed mind, but rather a matter of maintaining appropriate and necessary ethical restrictions under difficult circumstances.
In the following presentation of examples in the current setting, I rely primarily on talks I have had with practitioners of TCM during the past decade for information about how techniques are being incorporated into TCM practices. I have written extensively about the problems with incorporating such techniques and about the importance of challenging claims made for them (Dharmananda 1996, 1997a, 1998, 2000a, 2000b, 2000c, 2000e); the articles were mailed as they were produced to practitioners of Chinese medicine who joined ITM’s START Group. For purposes of discussion, I will give as examples the “diagnostic” technique of applied kinesiology (muscle testing) and the “therapeutic” technique of NAET (allergy-clearing therapy). I realize that those who have adopted these methods (and others of similar nature) into their practices will readily reject all that is to follow (arguing that they are absolutely certain of their efficacy); however, the discussion can be of benefit to those who have not yet done so and who may contemplate pursuing them.
Applied kinesiology has been widely introduced into Western TCM practices, I estimate 20% of U.S. licensed practitioners trained in the West, use it to some extent. Applied kinesiology is unproven (and easily disproved by using blinded samples); it has no basis in or consistency with TCM (it was devised by a chiropractor who had no TCM experience); and may divert practitioners from study of their field. Learning the technique may require only a few hours (if that) and it can be taught by anyone who is a self-proclaimed expert. For those not familiar with this practice, a common method of application is for the patient to hold some material (e.g., a bottle of herb pills) to their naval, and then hold out one arm parallel to the ground or hold their thumb and first finger together in a circle; the practitioner then presses down on the outstretched arm while the patient resists, or pulls on the two fingers held together with the patient resisting; if the muscles seem to give way easily, the remedy held in their hand is deemed wrong, while if the muscles seem to resist well, the remedy is deemed correct. For the average educated person, this technique—used for medical purposes rather than entertainment—may seem silly in the extreme; for practitioners who adopt it, this is a serious method based on the concept that the body does not lie, and that the body will accurately reflect the relative value of the remedy as detected through its “energy field” which then influences the strength of the tested muscles. The role of the practitioner is to apply the counter-pressure to the patient’s applied muscular tension; the result seems equally obvious to the patient and the practitioner, so there is no expertise required.
In speaking with and challenging practitioners who use the technique, defences for its use in a TCM practice include restricting its use (e.g., to cases where it is difficult to decide between two herbal formulations that might seem equally suitable), not relying solely on its use (e.g., using it only as a final “check” for decisions made on the basis of TCM), or claiming that it evidently helps the practitioner get good results, so its application is justified (e.g., “my practice is much more effective with it”). In all three instances, there is no established basis for determining that incorporation of applied kinesiology is of benefit whether it is widely applied or only for limited cases; in the last instance, the claim of benefit is made without considering the generally accepted means of making such judgments (that is, established methods of modern science, which has its foundation in evaluating the veracity of claimed outcomes). In a few cases, practitioners are swept into working with an entire theoretical framework of “body energetics” in which applied kinesiology plays a substantial role, and the practitioner no longer presents what he or she is doing in standard TCM terminology. As an example, one chiropractor-acupuncturist lists on his website the services he offers, saying that the therapeutic approach involves “acupuncture together with other methods” and includes homeopathy (another non-TCM practice, which is also not part of chiropractic), described this way: “the use of homeopathic remedies to enhance the body's ability to heal itself. We stock highly effective European homeopathics. Bach Flower Remedies are dispensed according to applied kinesiological testing to assure effectiveness.” An especially notable example of offering TCM and then “other” techniques is displayed in this example of a promotion for a clinic in the U.S:
“The medical philosophy [at our clinic] is based on Traditional Chinese Medicine (TCM) with acupuncture as the cornerstone of that philosophy….. As [our clinic] has evolved, our practitioners have embraced new forms of energetic healing. BioSET Allergy Elimination treatments and the Jaffe-Mellor Technique are two examples of this new energetic healing. Both use acupuncture and Traditional Chinese Medicine concepts, yet they bring them to a new level of assessment and treatment by implementing the modern discovery of muscle resistance testing (or applied kinesiology) as a way to obtain information directly from the body. These exciting new techniques have offered us new and powerful tools to help us reach our goal of healing the body, mind, and spirit!”
Practitioners who “embrace” these self-proclaimed higher level techniques often become involved further with non-TCM methods, using various electromagnetic testing devices, pursuing the angle that the body’s field can be measured in order to determine a treatment. The possible divergences from TCM practice are endless. Applied kinesiology may be well described as the first step onto the “slippery slope.” It is important to note that the description of evolution of the clinic did not involve, as examples: working at a TCM hospital in China for several weeks; acquiring and studying traditional Chinese medical texts; or undertaking an in-depth course in modern medicine so as to better integrate patient’s current medical care with the TCM methods to be offered. Instead, newness and excitement are the key words.
A retort by some of those who use applied kinesiology is to challenge the TCM system this way: ‘if kinesiology is questioned, then why not question pulse diagnosis as well?’ This point of potential dispute is raised because pulse diagnosis presents certain difficulties in understanding: it is claimed that by touching the body (mainly the wrist) in certain ways (i.e., holding three fingers at the radial artery and placing differing amounts of pressure), one can determine imbalances of the internal organ systems. This seems an incredible claim, and somewhat like the claim for kinesiology. In fact, pulse diagnosis is an unproven method. However, it differs from applied kinesiology in significant ways; in regard to the ethical question at hand, it is a different situation because it is an authentic aspect of TCM. A practitioner may decide not to rely heavily on pulse diagnosis or not to use it at all if he or she questions its value in the modern setting. However, the practitioner who utilizes it in a manner consistent with its use in TCM is relying on a part of the official training that is given for the original medical system (Dharmananda 2000d). Using traditional medicine systems does not require that each component of the system be proven valid or effective, because traditional medicine is a cultural construct that is being retained; however, introducing a non-traditional technique places an ethical burden on the one introducing it, especially if that person claims that, in fact, “it works.” Not only is patient care at stake, but also the reputation of the entire profession.
Adding a non-TCM technique which is claimed to improve the outcomes for patients must be considered in light of how the claim is being made. No one can deny the importance of helping patients and aiding their health care; a potential benefit to patients seems to outweigh a concern for authenticity and even scope of practice (if not invading the realm of modern medicine). However, it is far too easy to make a claim and to interpret observations as supporting the technique, when, in fact, such a claim is unjustified and the interpretation is faulty. It has been a failure of the education system in the West that most TCM practitioners are not trained in the method of evaluation and may not be adequately trained to understand the normal course of various diseases and disorders. TCM is not a profession unchangeably fixed in ancient practices; it is one that does become modified over time; for example, in China TCM blending with aspects of modern medicine is a common theme. However, the fact that the field is evolving does not mean that it is thrown open to incorporation of anything that captures the interest of the practitioner, as Huai Yuan so aptly stated.
A related problem is introduction of therapeutics (in contrast to diagnostics) that have little or no connection to TCM. Mentioned briefly above was homeopathics (and one of their recent derivatives called Bach Flower Remedies). A particularly insidious example affecting the TCM profession is NAET, which became popular a few years ago, involving hundreds of acupuncturists in the U.S., though it is now waning. Initially, it was claimed that this technique applied to allergy patients could cure allergies permanently within 24 hours. The therapy was developed by a young practitioner of chiropractic who was studying acupuncture. She incorporated the concepts of NLP (neurolinguistic programming), a bizarre system that was developed in California about thirty years ago, which has been widely adopted by chiropractors, the same group that initiated and has extensively used applied kinesiology (NLP has also been used in some other areas, like popularized negotiating strategies, because it involves trying to change people’s ideas, attitudes, and behaviours). Naturally, NAET failed to meet the initial claim, but it did attract many practitioners to offer prolonged, expensive treatment regimens to patients; the financial rewards has been one of the reasons for retaining it cited by practitioners who still offer NAET. The practitioners would, in many instances, even claim to cure an allergy that they themselves diagnosed, through methods such as applied kinesiology, thus making an internally self-satisfying system. Spin-offs of this technique (such as BioSET and Jaffe-Mellor Technique (JMT), mentioned in the clinic description quoted above) were then promulgated to offer cures not only of allergies, but of autoimmune diseases and numerous other recalcitrant health problems. Although use of acupuncture needles is a usual component of the therapy, no in-depth knowledge of TCM is required to apply NAET, BioSET, or JMT. Thus, these methods could give the external appearance of being authentic TCM, while actually being an unrelated practice. Claims of its effectiveness were arrived at easily by interpreting patient responses and case histories in unusual and limited ways.
There are no reputable studies demonstrating the effectiveness of either applied kinesiology or NAET that might be relied upon to help justify a need for them to be incorporated into a TCM practice. The explanations of how these techniques “work” given by proponents is based on descriptions of the body that are not consistent with what has been established through modern investigations; though they might remotely sound like explanations of TCM, they are, in fact, only superficially of any similarity. While the lack of studies or the non-standard explanation does not rule out the possible reality and effectiveness of the techniques, neither do the claims for them have any basis on which one could ethically introduce them into a licensed TCM practice. As with comparisons of applied kinesiology with pulse diagnosis, the theories behind NAET might be compared with certain concepts of the flow of qi (something that can not be shown by modern science) and the concept of unblocking qi to resolve diseases. As before, the proper description of qi circulation falls within the realm of authentic TCM, and practitioners can minimize or avoid the use of this description if they question its suitability in the modern context (for example, acupuncture effects can be described in terms of manipulations of the nervous system, circulatory system, and various signalling substances in the blood). Thus, comparisons to somewhat esoteric TCM concepts do not excuse the unchallenged introduction of a non-TCM technique that lacks both authenticity and valid proof of efficacy.
Practitioners who have used these techniques will no doubt find some patients who believe that it is these techniques that have helped them (rather than other, equally logical explanations). What is a practitioner to do if they realize that the methods offered have been provided with ethical problems as depicted above? What is needed is probably the same response ethically required when giving a patient a placebo. The placebo may be perceived to have made a huge difference; however, after a placebo controlled study is completed, the participants are permitted to know what they were taking and if the active compound used by others proved sufficiently safe and effective, they are given the opportunity to use it instead. While it might be ethical to offer to the placebo user the ability to continue using placebo (since it had appeared effective), it would be considered unethical to do so while claiming that it was the active compound. Similarly, patients who have been satisfied with such placebo-like techniques should be informed of their nature once it becomes known.
In their enthusiasm for offering these new techniques, practitioners may not realize that they are providing a certain deception. Patients may be attracted by the statements like these: “Acupuncture is a 5,000 year old medical science that is used worldwide; I am a licensed acupuncturist and studied 3 years [or more] at [name of college], an accredited institution.” The action, however, may be this (if defined honestly): “I am going to offer you a technique that is not anywhere near 5,000 years old, nor 500 years old, but less than 50 years old, for which I am not licensed by the State and which was not taught at an accredited college.”
It is important to restate the fact that TCM is not a closed or rigid system, so it is not inherently wrong to make changes. In recent years, certain herbs have been removed from the collection traditionally used because of concerns about toxicity or endangered species status; new preparations, such as dried extracts, that were not accessible decades or centuries ago may be incorporated. Ear acupuncture was developed in France, and although it has strong links to traditional acupuncture, it represents a new set of points. Pulsed electrical stimulation of acupuncture points to replace manual twirling or rapid push/pull techniques has been introduced in the past few decades. Although the significance of each of these changes should be carefully considered, it is evident that well-trained TCM practitioners working in China do not refuse to accept changes in TCM solely because they are not authentic to the ancient practices. On the other hand, none of these examples of changes are ones that are absent in China, none represent dramatic divergence from TCM, and they do not involve denial of the value of the original practices. The claims are that patients are protected from dangerous substances and the environment is protected from overcollection; ear points can be used like points on the head and other parts of the body, and pulsed stimulation by an electrical device is more or less equivalent in effect to physical pulsing done by hand. Limited claims and modifications help mark changes that fit the scope of practice for TCM. Even so, there are cautions to be raised. For example, with ear acupuncture, some people have simply invented point systems and made efficacy claims that, if simply accepted, lead one away from the in-depth study of TCM; the making of such claims without careful interpretation of cases can be an unethical action. In the cases cited above, of applied kinesiology and NAET, the claims are outlandish, the techniques are not accepted by the mainstream of practitioners in China, and they are not truly modifications of the existing authentic TCM.
It is essential that practitioners of Chinese medicine give serious consideration to the introduction of non-TCM techniques into their practice before including them. Schools of Chinese medicine and teachers in the field need to explicitly define what constitutes TCM and emphasize that it has characteristics which patients expect to encounter, including authenticity of the technique as part of TCM, training of the practitioner in the techniques they apply within the accredited courses, and reasonable interpretation of the scope of practice. The method for evaluating claims of effectiveness and evaluating patient responses to treatments need to become part of the TCM curriculum.
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